Each month Tina Marie Porter pays about $1,000 out of pocket for Mounjaro™ [tirzepatide]. To make up for the extra monthly expense, the 49-year-old director of operations takes on more assignments and seeks odd jobs. Porter belongs to a growing population of people taking extra measures to cover the full or almost-full price of popular drugs used for weight loss, after their insurance denied them coverage. “It is life changing”, said Porter, 49, of Kansas City, Mo. “But I shouldn’t have to pay because my insurance won’t cover it. It is making me healthier. It makes no sense.”
…They are also self paying for off-label use of Novo’s diabetes drug, Ozempic [semaglutide], and sister drug Wegovy, which is approved for weight loss. The willingness of consumers to pay thousands of dollars of their own money underscores the public’s appetite for more effective weight-loss medications, especially for people who have long struggled with obesity. The injectable medications can result in patients losing roughly more than 15% of their body weight.
…In Pittsburgh, Jordan Jones said she felt optimistic about her weight struggles when she heard about Ozempic. Then she found out her insurer wouldn’t cover the medication for off-label use. Her boyfriend is now working 12-hour shifts 4 days a week to pay for her $800 monthly supply. The couple is also cutting back on eating out, gas, groceries and alcohol, she said. “You would think it would be covered as preventive care”, said the 30-year-old who sells internet technology solutions. “I am lucky I can afford it out of pocket. I recognize my privilege. People want to feel healthy and they’ll get it any way they can.”
…For Barbara Clements, 70, of Orlando, Fla., the lack of coverage from Medicare is costing her about $1,000 a month for her Mounjaro prescription. The retired small-business owner says the cost is more than her monthly Social Security check. She and her wife clip coupons, ask for senior rates, and take buses instead of cabs. “It is an investment because in the long run it will save me money and it will save Medicare money by improving the quality of my life”, she said. “But I resent it. I see other people getting it covered and people selling it on the black market.”
…Many commercial health plans and federal programs such as Medicare won’t cover the drugs in part because they are viewed as lifestyle medications rather than lifesaving medications that treat the chronic disease of obesity. Only 43% of health-plan sponsors cover FDA-approved weight-loss drugs, according to a June report by Pharmaceutical Strategies Group, a pharmacy intelligence and technology company. Federal statute excludes coverage of anti-obesity medications in traditional Medicare, putting them largely out of reach for many of the roughly 65 million people on the program. Almost 42% of people ages 60 and older are obese, according to the Centers for Disease Control and Prevention…Medicaid, a program for low-income and disabled Americans, covers some of the newer weight-loss drugs in only about a dozen states, including Pennsylvania and California. States have the option, but aren’t required to cover anti-obesity medication, according to the Centers for Medicare and Medicaid Services. The Social Security Act as it applies to the Medicaid program says that states may exclude or restrict coverage of drugs used for weight loss. “From a historical perspective, people pretended obesity wasn’t really a medical condition, so a lot of prescription drug plans won’t cover it”, said Ted Kyle, former chair of the Obesity Action Coalition, a nonprofit representing individuals affected by the disease of obesity.